Erector Spinae Plane (ESP) Block: Indications and Procedure
Primary Indications
The erector spinae plane block is recommended as a first-line regional analgesia technique for video-assisted thoracoscopic surgery (VATS) and can be used for thoracic, abdominal, and hip surgeries requiring multimodal pain management. 1
Thoracic Surgery Applications
ESP block is specifically recommended for VATS as part of multimodal analgesia, showing non-inferiority to paravertebral block with comparable efficacy in reducing pain scores and opioid consumption during the first 48 hours postoperatively 1, 2
ESP block is particularly indicated when the parietal pleural leaflet is damaged, which would preclude the efficacy of a paravertebral block with catheter 1
The block provides effective analgesia with reduced pain scores and opioid consumption during the first 24 hours after VATS 2
Continuous ESP catheter placement improves Quality of Recovery-15 scores at 24 and 48 hours compared to paravertebral block 3
Cardiac Surgery
- ESP block is an acceptable alternative to thoracic epidural analgesia for cardiac surgery under cardiopulmonary bypass or off-pump procedures, with identical analgesic efficacy but fewer adverse effects 4
Breast Surgery
- For oncological breast surgery, ESP block reduces morphine consumption compared to general anesthesia alone, though PECS blocks demonstrate superior pain control after the first postoperative hour 5
Abdominal Surgery
ESP block provides both visceral and somatic analgesia for abdominal procedures including bariatric surgery, hernia repairs, and laparoscopic cholecystectomy 6, 7
The local anesthetic spreads into the paravertebral space, affecting ventral and dorsal branches of thoracic spinal nerves and sympathetic nerve fibers 6
Hip Surgery
- Lumbar ESP block (at L4 level) can serve as the main anesthetic technique for hip surgery in high-risk elderly patients when combined with mild sedation 8
Procedural Technique
Anatomical Level Selection
For VATS, perform a single injection at T4-T6 level rather than multiple injections, as multiple injections (T4-T8) have not demonstrated superior analgesia but increase procedural time and patient discomfort 2, 9
For bariatric and abdominal surgery, perform bilateral ESP blocks at T7 level to achieve visceral and somatic abdominal analgesia 7
For lumbar procedures, inject at L4 level between erector spinae muscles and transverse process 8
Ultrasound-Guided Technique
Use ultrasound guidance to identify the erector spinae muscle and transverse process at the target level 1
Inject local anesthetic into the fascial plane deep to the erector spinae muscle 7
The injectate spreads craniocaudally over several levels and penetrates anteriorly through intertransverse connective tissue into the paravertebral space 7
Dosing Recommendations
The recommended volume is 20 ml of bupivacaine 5 mg/ml (0.5%) for single-shot ESP block 2
For continuous infusion via catheter: administer 20 ml bolus of levobupivacaine 0.375% followed by infusion of levobupivacaine 0.15% at 10-15 ml/hour for 48 hours 3
For abdominal surgery: 40 ml of local anesthetic mixture (20 ml bupivacaine 0.5%, 10 ml lidocaine 2%, and 10 ml normal saline) 8
Adjuvant Considerations
Adding dexmedetomidine to ropivacaine in ESP block results in reduced pain scores, lower rescue analgesia requirements, and shorter hospital stays compared to plain ropivacaine 2
Consider adjuvants when prolonged analgesia beyond 6-8 hours is required 2
Timing
- No significant difference exists between blocks performed after incision or at the end of the procedure in terms of pain scores and opioid consumption 2
Clinical Outcomes
Efficacy Metrics
ESP block significantly reduces pain scores at rest and during coughing for the first 6-8 hours after VATS compared to placebo 2
Patients demonstrate lower opioid consumption during the first 24 hours postoperatively 2, 10
Faster postoperative out-of-bed activity occurs with ESP block 2
Meta-analysis shows ESP block reduces 24-hour postoperative opioid consumption (mean difference -17.49 mg morphine equivalents) and pain scores at rest and movement 10
Safety Profile
The incidence of hematoma is lower with ESP block compared to other regional blocks (odds ratio 0.19) 10
ESP block avoids the risks of hypotension, urinary retention, and lower limb weakness associated with thoracic epidural 1
Critical Caveats and Pitfalls
Duration Limitations
The analgesic effect of single-shot ESP block diminishes after 6-8 hours, requiring supplemental analgesia 2
- Always administer basic analgesia with NSAIDs and paracetamol concurrently with ESP block to optimize pain management 2
Comparative Effectiveness
Some studies suggest paravertebral block may provide superior analgesia compared to ESP block in the first 8 hours after surgery 2
ESP block may provide less consistent analgesia compared to paravertebral block in some patients, requiring careful assessment of individual pain control 2
For breast surgery, PECS blocks demonstrate superior outcomes after the first postoperative hour compared to ESP block 5
Anatomical Limitations
- Neither ESP nor PECS blocks reliably provide sufficient analgesia to the axilla (T1 nerve distribution), requiring supplemental local anesthetic wound infiltration for axillary procedures 5